Fighting a growing enemy

Cancer is the fastest growing killer in the Middle East and a united front is needed to tackle a looming health crisis.

The incidence of cancer in the Middle East is expected to double in the next ten years, a higher increase than in any other part of the world1, and health authorities are calling for a coordinated response to the growing burden.

While the current incidence is three to four times lower in the Middle East than in the developed world, survival rates are significantly lower than those in North America and Western Europe, and about half of all cases occur before the age of 55, between 10-20 years earlier than in industrialised nations.

In the past decade, several international organizations have been set up to tackle the cancer burden in the Middle East. Various research institutions in the region are now involved in clinical trials testing new ways to detect and treat the disease, as well as basic oncology research.

Lack of data

One big challenge is the lack of records. "There was already a registry in Israel, plus small pockets in Cairo and Alexandria, but not in other countries," says Michael Silbermann, co-founder and executive director of the Middle East Cancer Consortium (MECC), an intergovernmental organization that was established in 1996, following an agreement between the Ministries of Health of Cyprus, Egypt, Israel, Jordan, the Palestinian Authority and, in 2004, Turkey.

"Everybody involved understood that cancer was going to become a real health issue in the Middle East," Silbermann continues, "but nobody knew the burden of the disease, so one of the first things we did was set up a cancer registry network in all the participating countries."

Breast cancer is by far the most predominant form in the Middle East, followed by bladder, lung, oral, and colon cancer. Survival rates for breast cancer are very high at the earliest stages. But their newly-acquired data showed Silbermann and his colleagues that a significant majority of cancer patients in the Middle East do not see a physician until it is too late. In Jordan, Egypt, Syria and Sudan, more than 65% of breast cancer cases are detected only at advanced stages, by which time they are inoperable.

In other countries, the situation is different. "We have to distinguish the Gulf states from other Middle Eastern countries," says Arash Rafii of Weil Cornell Medical College in Doha. "In the Gulf, patients have very good access to healthcare. Here in Doha everyone gets screened. In other countries, the screening process and access to healthcare are not as good, so patients are under-diagnosed. If you're in a small village in Morocco, you're not going to get screened."

Silbermann agrees that access to health care is a problem in many rural parts of the Middle East. "So many women do not go to a physician unless their cancer advances to the stage at which it is causing pain, or when necrotic lesions develop," he says.

Another barrier to early detection and treatment is the cultural issue surrounding the disease. Cancer is still strongly stigmatised in many Middle Eastern countries, making women less likely to seek help.

Even when patients do seek diagnosis, they often cannot afford the necessary drugs. "A mega challenge to the management of cancer patients in Egypt is poor accessibility to the new generation of medications," says Hamdy Azim, a clinical oncologist at Cairo University. "These drugs are very expensive, but they are not covered by the Ministry of Health, so they have to be paid for out of pocket."

In 1992, Azim founded the Cairo Oncology Center, the biggest private cancer facility in the Middle East. It treated 1,750 new patients last year, and now has 43 members of staff, including 18 oncologists, pharmacists, medical data managers, a palliative care consultant and a specialist in the psychology of womens' cancer. The centre has participated in numerous international clinical trials over the past 15 years, and is involved in several more.

Habits and rising incidence

The most important thing to reduce cancer burden in these countries is to improve access to healthcare.

"The goal is to use systems biology approaches to understand how ovarian cancer cells interact with their microenvironment," he says. "We are now moving on to functional oncogenomics. We have obtained tumours from different centres around the world, and are studying them to see how tumour heterogeneity affects treatment and diagnosis."

Rafii's group is also doing research into the types of cancer prevalent in the region. "There's a certain form of breast cancer – inflammatory breast cancer – which has a slightly higher prevalence in the Middle East," he says. "We're also going to start a programme for endometrial cancer, which is very prevalent due to high level of diabetes in the region."

The dramatic rise in cancer prevalence in the Middle East is partly due to increased life expectancy and to lifestyle changes. "Many people in this part of the world have adopted a Westernised style of life," says Silbermann. "Their diet has changed, and they don't take as much exercise as they used to."

Smoking is another factor. Tobacco use is increasing throughout the region, especially among women and young people. In the past decade, water pipe smoking has become a fashionable trend and is likely be linked to the high prevalence of lung and oral cancers.

"The high incidence of smoking from a young age is just one of several challenges" to reducing the cancer burden in the region, says Azim. "Others include extreme obesity, high prevalence of hepatitis C virus [which is associated with liver cancer], and industrial and agricultural pollution."

Silbermann says increased awareness of the disease is essential to reduce its burden: "Education, education, education. If somebody feels something strange, they should go to a doctor or medical centre as early as possible."

He is optimistic for the future, emphasising the fact that countries such as Egypt, Israel, Qatar and Saudi Arabia are "extremely interested" in developing and promoting cancer research, and are investing in education and training surrounding the disease. Paramount in these efforts will be preventative measures that seek to raise peoples' awareness of, and minimise their exposure to, known environmental risk factors, such as tobacco smoking.

"The most important thing to reduce cancer burden in these countries [outside the Gulf] is to improve access to healthcare." says Rafii, "The second is to build structured networks to drive clinical trials and improve the standard of care." Better healthcare systems focused on cancer will need financial commitment and political will to go together, he adds.

doi:10.1038/nmiddleeast.2013.146

World Health Organization. Towards a strategy for cancer control in the Eastern Mediterranean Region. Cairo, Egypt: WHO/EMRO (2009).